Yesterday’s emergency patient arrived after she’d collapsed at the groomer’s after a rough night of intermittent restlessness. She’d perked up with a pain-reliever by breakfast-time (prescribed for her severe osteoarthritis), which is presumably why her owner thought she’d keep her appointment with the groomer.
In hind-sight it’s obvious her first step should’ve been the vet’s—though the end result of the morning’s trials would have been the same.
Soaking wet, lying on her side and breathing hard, ten year-old Stormy was alert enough to register severe pain. Bloody diarrhea was pouring from her backside, which her devoted groomer bravely sought to contain with a blanket.
This man deserves a medal, I thought. He’d be losing all his Saturday morning business to be here at Stormy’s owner’s request—no small percentage of his weekly take, I figured. Yet he felt especially responsible for her well-being, considering he’d known she was feeling poorly from the look in her eyes before he carried her into his tub for a bath.
That’s where she’d gone down, even before he’d applied the shampoo. Ten minutes later he’d driven her to our hospital himself when it was clear her owner could not make it back from a faraway site in time.
Now he was here, wishing he’d heeded the advice of his inner voice when he’d first seen Stormy walk in that day. “It was more than just her arthritis,” he’d confessed to me in his Portuguese-accented Spanish. “She looked defeated. In her eyes.”
By this time she’d received fluids and pain relievers and we were hauling her 100-pound bulk cautiously onto the stretcher for X-rays. Meanwhile, I’d reached Stormy’s owner on her mobile and wasn’t getting the “I’ll be there immediately” sense of urgency I sought.
By this time I was beginning to feel pretty downcast about her chances since I thought I could feel a large mass in her abdomen (despite the presence of abdominal fluid and her painful reluctance to be palpated) and I was hoping to demonstrate its enormity by way of impressing upon her owner the need to make quick decisions—in person, preferably.
No dice. Despite the presence of a grapefruit-sized hulk of firm tissue staring at us from the film, the owner was still a no-show. She’d asked me to wait until she could locate her family before making a decision as to the next step: surgery, specialist, 24-hour care, etc.
And here’s where my moral dilemma for the morning makes its debut in the story:
Stormy is still painful but just barely registering decent blood pressure and tissue oxygenation. Do I provide more pain relievers and risk the poor outcome of a surgical approach if this is what the owners ultimately elect? Or do I simply administer the drugs, accepting that pain relief trumps everything in a crisis like this?
At issue is the difference between how we minister to animals and how humans are treated in critical care settings. We humans are typically granted the right to suffer extremes of pain and discomfort in our sometimes slavish acceptance of the fact that the end justifies the means when it comes to saving lives through medicine.
The same is not true for animals. We assume that suffering is perceived differently by animals, that their limited cognition means an understanding of their own pain eludes them—especially because we believe they cannot see beyond the pain to a time when they will be free of it.
I the end that’s why I gave another whopping dose of pain reliever. I had warned the owners that the longer they waited the greater the chance that Stormy would succumb. The way I see it, the need for me to provide pain relief in lieu of definitive treatment is one of those time-sensitive factors that often plays into the ultimate cause of death.
In the end it was worth it. After another thirty minutes, Stormy’s widening pool of owners called with their collective decision to euthanize her. By this time she had finally relaxed somewhat. Her breathing had become more shallow and her heart rate had slowed.
Sure, she was closer to death after I’d relieved the bulk of her pain. If the decision to treat her surgically had been handed down it’s true that my heavy-handedness with a syringe might have forestalled an eventual recovery.
Nonetheless my philosophy stands: If an animal is in so much pain that his demise via pain relief is a potential outcome, I feel even more justified in pushing it.
RIP, Stormy. Feels better now, doesn't it?
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Good for you Dr. Khuly. She deserved some relief. So sad that the groomer could see in her eyes that she was ill when her owners were oblivious. I think vets and pediatricians have a particularly difficult task in treating patients. Its not the patients that are the problem, it’s the responsible parties not being responsible for their charges. Wish I lived closer to you and I’d take the name of that groomer.
Shannon Watts August 17th, 2008 11:42:00 AM
Ditto: Bless you both! And RIP Stormy--what do you feel ruptured? spleen, maybe? The sadness, of the non-committal owners makes for huge stress for both you & the groomer. The groomer was Stormy's advocate for sure.
Barbara A. Albright/New Hampshire August 17th, 2008 12:34:00 PM
They "called" in their decision to euthanize her, how sad. I cannot imagine what would keep me from my pets side in such a situation. She gave them 10 years and they could not be there even to say good bye.
Elizabeth - from Nova Scotia August 17th, 2008 12:55:00 PM
I have had clients do similar things in that they will "stall" in making a decision until there really is no alternative except euthanasia. Sometimes, I think it is done with the idea that " if I wait, I won't have to make any decision at all." For some, it is beyond their capability to say the actual words that will give us permission to end a pet's life. Doing so over the phone is easier for some people. I had one client with a very aged and frail toy poodle who signed a euthanasia consent every time she left town because she doesn't want to know if the dog fell apart and had to be euthanized while she was away. She says that she knows that if we were to call her, she will feel compelled to tell us to do everything to save her, but that would not be the best thing for a 17 year old dog in renal and heart failure. Thankfully, the little thing died at home in the night and we were never faced with any sort of situation.
Personally, I put pain control and comfortable breathing above all else. I know I would take a half hour of comfortable goodbyes with my family over a month of agony. Quality over quantity, I say.
Lisa August 17th, 2008 02:29:00 PM
"I know I would take a half hour of comfortable goodbyes with my family over a month of agony."
I agree. My guideline for making these decisions has always been, "better three days early than three minutes late."
Gina Spadafori August 17th, 2008 02:58:00 PM
Thank God you had the cojones to do what was best for Stormy. Sometimes, all you CAN do is relieve pain and suffering. And the gift to be able to recognize that is priceless.
On a similar note, my dad had terminal cancer and was dying- the nurses were withholding his pain meds because they wanted him to be alert for the family and friends who were visiting from out of town. After noticing his distress and anxiousness, I asked why the morphine wasn't working. The nurse explained they weren't giving it so he would be alert. Very quickly my sister and I had a come-to-God meeting with the staff and his morphine was given. He died a few hours later, without pain, and without being alert for his visitors.
Sometimes I really wonder what is going through peoples' minds.....
RIP Stormy.
agadoresmama August 17th, 2008 11:14:00 PM
RIP Stormy.....So sad that out of a wide pool of owners, no one was there to be with Stormy when she passed. This breaks my heart. Thankfully she had you Dr. Patty.
Out of curiosity, what percentage of your clients would you say are present for the euthanizing of a pet (versus via a phone call or a drop off and leave scenario)?
Creature of Habit August 18th, 2008 08:35:00 AM
Creature of Habit: Luckily, it's about 80% or so of my clients who choose to be with their pet. Some clients just can't watch, though, and they trust us to be kind and humane. Very few drop off disinterestedly.
Dr. Patty Khuly August 18th, 2008 08:45:00 AM
I have had that brain freeze moment about euthanasia with a research animal. And this is after we had months of establishing protocol, thinking of everything that could go wrong and deciding exactly what should be done. If anyone should have been prepared. We had decided that if we were very unlucky and a pig got a certain kind of infection the humane thing to do was euthanise because recovery was almost impossible. The vet inspected a listless pig and said she had the infection. What did I do? I *asked* the vet what we should do. Of course we then followed the protocol and I cried for three days. I think it is difficult to take responsibility for a timely euthasia decision but the animal shouldn't suffer during our dithering, even as you say if this starts to have some health implications.
emily August 18th, 2008 09:30:00 AM
Dr Khuly, you did the right thing. I wish that all veterinarians placed pain control as a high priority.
Six years ago I received a Monday morning call from an emergency clinic an hour from me. They had a bulldog in their care. She was 5 years old, had badly infected ears and a "shattered" rear leg that would require amputation. The owners had brought her in to be euthanized the previous evening, after she had been stepped on by their horse when she did not hear it approaching due to the bloody pus running from both ears.
The tech on duty knew me, knew I did rescue and persuaded the owners to let them place her in rescue if possible. I told the vet who called me that yes! I would be right down.
Then I asked what had been done for her. Answer? Nothing.
No IV to combat shock. No Pain control at all. No splint on the crushed limb. No x-rays to confirm the diagnosis of "unfixable." Nada. and she had been there for 14 hours already.
Why not? because the woman had figured we would not want her and she was going to be put down anyway and she was not screaming in pain. (bulldogs often don't show the agony they are in. Break a nail or have a sore tail the world is ending, break a leg and they will just stoically sit there).
So after counting to ten and giving the clinic my credit card info I asked that she get pain control, a splint and an IV set please and I would be there shortly. It took me an hour and a half to get to the clinic as it was rush hour. When I inquired if she was ready to go I was told "No, they just started working on her"
By the time I got Sweetpea in the car, she was going into shock. She still had no IV and her reserves for dealing with the trauma and pain were gone. Her gums were pale and cold and she screamed every time I went over even a pebble in the road, the 10 minute drive to my vet's office was one of the longest of my life. Upon arrival at the other clinic my veterinarian came out to the car to see her and immediately started an IV, gave her morphine and then helped the techs and myself move her onto a stretcher. Inside she got warm blankets and fluids to combat shock and bring her body temp up to something near normal. No one wanted to even try to examine her leg or ears until she was stable and her pain was under control.
The good news was that her "shattered, unfixable " leg was actually a very staight forward although impressive tib-fib fracture and she walked out of the clinic on it 4 days later with the help of a large bone plate. her ears were a chronic issue but she ultimately went to a home with an owner experienced with such things.
But six years later I still become angry when I think about her sitting with an unsplinted, unstable fracture for 14 hours when pain relief was literally a few feet away.
JenniferJ August 18th, 2008 11:49:00 AM
It is good to read that an impression of an animal suffering stays with someone for the betterment in the future. Obviously, a big part of my grief is surrounded by how many professionals knew my dog was bearing huge pain, untreated, unable to cry out as is the case with all dying animals. And to be deceived by all, that she was doing "well & would go home"
Barbara A. Albright/New Hampshire August 18th, 2008 05:07:00 PM
You're on a roll, Dr. Patty! This is a great post, as is the "10 things to know about renal failure". (btw, similar lists for other conditions would be GREAT!).
Pain control is a personal priority of mine too. I would rather have a vet accidentally euthanize my pet than have said pet suffer for hours. Also - a question for Dr. Patty and the other vets who read this - do you find that owners are reluctant to use anti-inflammatories or other pain meds for arthritic animals due to the negative press about Rimadyl? I know several people - otherwise really responsible and empathic pet owners - who refuse to acknowledge the pain their old pets are in. And I think the primary reason they refuse to see it is that they are more afraid of giving the pet "drugs" than they are of having the pet be uncomfortable.
Barb August 18th, 2008 11:14:00 PM
Barb: Yes, that's true. When Rimadyl made the rounds in press rooms across the US many of our clients whose dogs were ding well on Rimadyl wanted to discontinue the drug, despite the significant increase in these pets' quality of life. It was pretty frustrating at the time, especially since other NSAIDs were less studied back then. Fast forward three or four years and I see a lot less resistance to the use of NSAIDs in general--and precious few major side-effects to Rimadyl or other NSAIDs (when used judiciously).
Dr. Patty Khuly August 19th, 2008 08:53:00 AM
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